RESUMO
RATIONALE: Cervical radiculopathy is initially typically managed conservatively. Surgery is indicated when conservative management fails or with severe/progressive neurological signs. Personalised multimodal physiotherapy could be a promising conservative strategy. However, aggregated evidence on the (cost-)effectiveness of personalised multimodal physiotherapy compared to surgery with/without post-operative physiotherapy is lacking. AIM/OBJECTIVES: To systematically summarise the literature on the (cost-)effectiveness of personalised multimodal physiotherapy compared to surgery with or without post-operative physiotherapy in patients with cervical radiculopathy. METHODS: PubMed, Embase, CINAHL, PsycINFO and Web of Science were searched from inception to 1st of March 2023. Primary outcomes were effectiveness regarding costs, arm pain intensity and disability. Neck pain intensity, perceived recovery, quality of life, neurological symptoms, range-of-motion, return-to-work, medication use, (re)surgeries and adverse events were considered secondary outcomes. Randomised clinical trials comparing personalised multimodal physiotherapy versus surgical approaches with/without post-operative physiotherapy were included. Two independent reviewers performed study selection, data-extraction, and risk of bias assessment using the Cochrane RoB 2 and Consolidated Health Economic Evaluation Reporting Standards statement. Certainty of the evidence was determined using Grading of Recommendations, Assessment, Development and Evaluations. RESULTS: From 2109 records, eight papers from two original trials, with 117 participants in total were included. Low certainty evidence showed there were no significant differences on arm pain intensity and disability, except for the subscale 'heavy work' related disability (12 months) and disability at 5-8 years. Cost-effectiveness was not assessed. There was low certainty evidence that physiotherapy improved significantly less on neck pain intensity, sensory loss and perceived recovery compared to surgery with/without physiotherapy. Low certainty evidence showed there were no significant differences on numbness, range of motion, medication use, and quality of life. No adverse events were reported. CONCLUSION: Considering the clinical importance of accurate management recommendations and the current low level of certainty, high-quality cost-effectiveness studies are needed.
Assuntos
Análise de Custo-Efetividade , Modalidades de Fisioterapia , Radiculopatia , Humanos , Terapia Combinada , Cervicalgia/terapia , Cervicalgia/economia , Modalidades de Fisioterapia/economia , Qualidade de Vida , Radiculopatia/terapia , Radiculopatia/economiaRESUMO
PURPOSE: For cervical nerve root compression, anterior cervical discectomy with fusion (anterior surgery) or posterior foraminotomy (posterior surgery) are safe and effective options. Posterior surgery might have a more beneficial economic profile compared to anterior surgery. The purpose of this study was to analyse if posterior surgery is cost-effective compared to anterior surgery. METHODS: An economic evaluation was performed as part of a multicentre, noninferiority randomised clinical trial (Foraminotomy ACDF Cost-effectiveness Trial) with a follow-up of 2 years. Primary outcomes were cost-effectiveness based on arm pain (Visual Analogue Scale (VAS; 0-100)) and cost-utility (quality adjusted life years (QALYs)). Missing values were estimated with multiple imputations and bootstrap simulations were used to obtain confidence intervals (CIs). RESULTS: In total, 265 patients were randomised and 243 included in the analyses. The pooled mean decrease in VAS arm at 2-year follow-up was 44.2 in the posterior and 40.0 in the anterior group (mean difference, 4.2; 95% CI, - 4.7 to 12.9). Pooled mean QALYs were 1.58 (posterior) and 1.56 (anterior) (mean difference, 0.02; 95% CI, - 0.05 to 0.08). Societal costs were 28,046 for posterior and 30,086 for the anterior group, with lower health care costs for posterior (12,248) versus anterior (16,055). Bootstrapped results demonstrated similar effectiveness between groups with in general lower costs associated with posterior surgery. CONCLUSION: In patients with cervical radiculopathy, arm pain and QALYs were similar between posterior and anterior surgery. Posterior surgery was associated with lower costs and is therefore likely to be cost-effective compared with anterior surgery.
Assuntos
Vértebras Cervicais , Análise Custo-Benefício , Discotomia , Radiculopatia , Fusão Vertebral , Humanos , Radiculopatia/cirurgia , Radiculopatia/economia , Masculino , Feminino , Pessoa de Meia-Idade , Fusão Vertebral/economia , Fusão Vertebral/métodos , Vértebras Cervicais/cirurgia , Discotomia/economia , Discotomia/métodos , Adulto , Idoso , Foraminotomia/métodos , Foraminotomia/economia , Resultado do Tratamento , Anos de Vida Ajustados por Qualidade de VidaRESUMO
BACKGROUND: A recent randomized controlled trial (RCT), performed by the authors, comparing early surgical microdiscectomy with 6 months of nonoperative care for chronic lumbar radiculopathy showed that early surgery resulted in improved outcomes. However, estimates of the incremental cost-utility ratio (ICUR), which is often expressed as the cost of gaining one quality-adjusted life year (QALY), of microdiscectomy versus nonsurgical management have varied. Radiculopathy lasting more than 4 months is less likely to improve without surgical intervention and may have a more favorable ICUR than previously reported for acute radiculopathy. QUESTION/PURPOSE: In the setting of chronic radiculopathy caused by lumbar disc herniation, defined as symptoms and/or signs of 4 to 12 months duration, is surgical management more cost-effective than 6 months of nonoperative care from the third-party payer perspective based on a willingness to pay of less than CAD 50,000/QALY? METHODS: A decision analysis model served as the vehicle for the cost-utility analysis. A decision tree was parameterized using data from our single-center RCT that was augmented with institutional microcost data from the Ontario Case Costing Initiative. Bottom-up case costing methodology generates more accurate cost estimates, although institutional costs are known to vary. There were no major surgical cost drivers such as implants or bone graft substitutes, and therefore, the jurisdictional variance would be minimal for tertiary care centers. QALYs derived from the EuroQoL-5D were the health outcome and were derived exclusively from the RCT data, given the paucity of studies evaluating the surgical treatment of lumbar radiculopathy lasting 4 to 12 months. Cost-effectiveness was assessed using the ICUR and a threshold of willingness to pay CAD 50,000 (USD 41,220) per QALY in the base case. Sensitivity analyses were performed to account for the uncertainties within the estimate of cost utility, using both a probabilistic sensitivity analysis and two one-way sensitivity analyses with varying crossover rates after the 6-month nonsurgical treatment had concluded. RESULTS: Early surgical treatment of patients with chronic lumbar radiculopathy (defined as symptoms of 4 to 12 months duration) was cost-effective, in that the cost of one QALY was lower than the CAD 50,000 threshold (note: the purchasing power parity conversion factor between the Canadian dollar (CAD) and the US dollar (USD) for 2019 was 1 USD = 1.213 CAD; therefore, our threshold was USD 41,220). Patients in the early surgical treatment group had higher expected costs (CAD 4118 [95% CI 3429 to 4867]) than those with nonsurgical treatment (CAD 2377 [95% CI 1622 to 3518]), but they had better expected health outcomes (1.48 QALYs [95% CI 1.39 to 1.57] versus 1.30 [95% CI 1.22 to 1.37]). The ICUR was CAD 5822 per QALY gained (95% CI 3029 to 30,461). The 2-year probabilistic sensitivity analysis demonstrated that the likelihood that early surgical treatment was cost-effective was 0.99 at the willingness-to-pay threshold, as did the one-way sensitivity analyses. CONCLUSION: Early surgery is cost-effective compared with nonoperative care in patients who have had chronic sciatica for 4 to 12 months. Decision-makers should ensure adequate funding to allow timely access to surgical care given that it is highly likely that early surgical intervention is potentially cost-effective in single-payer systems. Future work should focus on both the clinical effectiveness of the treatment of chronic radiculopathy and the costs of these treatments from a societal perspective to account for occupational absences and lost patient productivity. Parallel cost-utility analyses are critical so that appropriate decisions about resource allocation can be made. LEVEL OF EVIDENCE: Level III, economic and decision analysis.
Assuntos
Discotomia/economia , Deslocamento do Disco Intervertebral/economia , Deslocamento do Disco Intervertebral/terapia , Microcirurgia/economia , Modalidades de Fisioterapia/economia , Radiculopatia/economia , Radiculopatia/terapia , Adulto , Análise Custo-Benefício , Discotomia/métodos , Feminino , Humanos , Vértebras Lombares , Masculino , Microcirurgia/métodos , Pessoa de Meia-Idade , Medição da Dor , Qualidade de Vida , Anos de Vida Ajustados por Qualidade de VidaRESUMO
Recently, there has been significant interest in understanding the cost-effectiveness of treatments in spine surgery as health care systems in the United States move toward value-based care and alternative payment models. Previous studies have shown comparable outcomes of cervical disc arthroplasty (CDA) and anterior cervical discectomy fusion; however, there is a lack of consensus on the cost-effectiveness of CDA to support full adoption. Evidence of the limitations of these cost-analysis studies also exists in the literature, including industry funding, potential selection bias, and varying methods of calculating value. The goal of this narrative review is to provide an overview of the cost-effectiveness of CDA compared with anterior cervical discectomy and fusion, and potential limitations with cost-analysis studies in spine surgery.
Assuntos
Vértebras Cervicais/cirurgia , Discotomia/economia , Degeneração do Disco Intervertebral/cirurgia , Fusão Vertebral/economia , Substituição Total de Disco/economia , Análise Custo-Benefício , Custos e Análise de Custo , Humanos , Degeneração do Disco Intervertebral/complicações , Degeneração do Disco Intervertebral/economia , Medidas de Resultados Relatados pelo Paciente , Anos de Vida Ajustados por Qualidade de Vida , Radiculopatia/economia , Radiculopatia/etiologia , Radiculopatia/cirurgia , Compressão da Medula Espinal/economia , Compressão da Medula Espinal/etiologia , Compressão da Medula Espinal/cirurgia , Estados UnidosRESUMO
OBJECTIVE: Epidural steroid injections (ESIs) are a commonly used treatment strategy for low back pain and lumbar radiculopathy. However, their cost-effectiveness and ability to mediate long-term quality of life (QOL) improvements is debated. We sought to analyze the cost-effectiveness of lumbar epidural steroid injections (ESIs) compared to medical management alone for patients with lumbar radiculopathy and low back pain. PATIENTS AND METHODS: QOL outcomes were prospectively collected at 3- and 6-months following initial consultation. Metrics included the EuroQol-5 Dimensions (EQ-5D) questionnaire, the Pain Disability Questionnaire (PDQ), the Patient Health Questionnaire (PHQ-9) and the Visual Analogue Scale (VAS). Cost estimations were based on Medicare national payment amounts, median income, and missed workdays. A cost-utility analysis was performed based upon cost estimations and a cost-effectiveness threshold of $100,000/Quality-adjusted life year (QALY). RESULTS: One hundred forty-one patients met our inclusion/exclusion criteria; 89 received ESI and 52 were treated with medical management alone. Both cohorts showed improved EQ-5D scores at 3 months but were similar to one another: ESI (ΔEQ-5D = 0.06; p = 0.03) and medical-alone (ΔEQ-5D = 0.07; p = 0.03). No significant difference was seen between groups for total costs ($2,190 vs. $1,772; p = 0.18) or cost-utility ratios ($38,710/QALY vs. $27,313/QALY; p = 0.73). At both the 3-month and 6-month endpoints, absolute differences in cost-utility was driven by overall costs as opposed to QALY gains. Medical management alone was more cost effective at both points owing to lower expenditures, however these differences were not significant. No benefits were seen in either group on the EQ-5D or any of the patient reported outcomes at the 6-month time point. CONCLUSION: ESIs were not cost-effective at either the 3-month or 6-month follow-up period. At 3 months, ESIs provide similar improvements in QOL outcomes relative to medical management and at similar costs. At 6 months, neither ESIs nor conservative management provide significant improvements in QOL outcomes.
Assuntos
Analgésicos não Narcóticos/uso terapêutico , Analgésicos Opioides/uso terapêutico , Glucocorticoides/administração & dosagem , Injeções Epidurais/economia , Dor Lombar/terapia , Fármacos Neuromusculares/uso terapêutico , Radiculopatia/terapia , Idoso , Tratamento Conservador , Análise Custo-Benefício , Feminino , Humanos , Degeneração do Disco Intervertebral/complicações , Dor Lombar/economia , Dor Lombar/etiologia , Dor Lombar/fisiopatologia , Vértebras Lombares , Masculino , Pessoa de Meia-Idade , Medição da Dor , Questionário de Saúde do Paciente , Modalidades de Fisioterapia , Qualidade de Vida , Anos de Vida Ajustados por Qualidade de Vida , Radiculopatia/economia , Radiculopatia/etiologia , Radiculopatia/fisiopatologia , Estenose Espinal/complicações , Espondilose/complicaçõesRESUMO
Background: The efficiency and effectiveness of multiple physical therapy care delivery models can be measured using the value-based care paradigm. Entering physical therapy through direct access can decrease health-care utilization and improve patient outcomes. Limited evidence exists which compares direct access physical therapy to referral using the value-based care paradigm specific to cervical spine radiculopathy. Case Description: The patient was a 39-year-old woman who presented to physical therapy through physician referral with the diagnoses of acute cervical radiculopathy. The patient was evaluated, provided guideline adherent treatment and discharged with a home exercise program. Sixteen months from being discharged, the same patient returned through direct access due to an acute onset of cervical spine symptoms and was evaluated and provided treatment that same morning. Outcomes: Direct access physical therapy saved the patient and third-party payer $434.30 and $3264.75 respectively. A 5×'s higher efficiency per visit and a 6.2×'s higher value in reducing disability was demonstrated when the patient accessed physical therapy directly. Physician referral and direct access entry pathways demonstrated neck disability index improvements of 6% and 16%, respectively. Discussion: This case report describes a clinical example of previous research that demonstrates improved cost efficiency, outcomes, and increased value with a patient who presented to physical therapy with cervical radiculopathy through two different access to care models. The results of this case demonstrate a clinical example of the use of the value-based care paradigm in comparing value and efficiency of two access to care models in a patient with cervical radiculopathy without other neurological deficits.
Assuntos
Acessibilidade aos Serviços de Saúde/economia , Cervicalgia/economia , Cervicalgia/terapia , Modalidades de Fisioterapia/economia , Radiculopatia/economia , Radiculopatia/terapia , Adulto , Análise Custo-Benefício , Avaliação da Deficiência , Feminino , Humanos , Cervicalgia/fisiopatologia , Medição da Dor , Radiculopatia/fisiopatologia , Encaminhamento e Consulta/economiaRESUMO
BACKGROUND: Anterior cervical discectomy with fusion (ACDF) or posterior cervical foraminotomy (PCF) are the mainstay surgical treatment options for patients with degenerative cervical radiculopathy (DCR). OBJECTIVE: To compare 90-d bundled payments between ACDF and PCF for DCR in a cohort study. METHODS: Data were extracted from MarketScan database (2000-2016) using ICD-9, ICD-10, and CPT-4 codes. The bundle payments were calculated as the payments accumulated from the index hospitalization admission to 90 d postsurgery. We also analyzed the index hospitalization (physician, hospital, and total) and the postdischarge payments (hospital readmission, outpatient services, medications, and total). Surgical groups were matched based on baseline characteristics (age, sex, insurance type, and Elixhauser score). RESULTS: A total of 100 041 patients met the inclusion criteria. 94.9% of patients (n = 95 031). Patients underwent ACDF with 5.1% (n = 5 010) treated via PCF. Overall, median 90-d costs were significantly higher for ACDF than for PCF ($31567 vs $18412; P < .0001). The median total index hospitalization ($27841 vs $15043), physician ($4572 vs $1920), and hospital payments ($14540 vs $7404) were higher for ACDF compared to PCF for both single- and multiple-level cohorts (P < .0001). There was no difference in overall 90-d postdischarge payments. Factors associated with higher 90-d payments for both cohorts included age and comorbidity scores. CONCLUSION: ACDF is associated with greater bundle payments in patients diagnosed with DCR. No difference was noted for the total postdischarge payments. PCF may be a cost-effective surgical option in appropriately selected patients with unilateral, paracentral, and foraminal soft herniated discs.
Assuntos
Vértebras Cervicais/cirurgia , Análise Custo-Benefício/tendências , Discotomia/tendências , Foraminotomia/tendências , Radiculopatia/cirurgia , Fusão Vertebral/tendências , Adulto , Estudos de Coortes , Discotomia/economia , Feminino , Foraminotomia/economia , Hospitalização/economia , Hospitalização/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Radiculopatia/economia , Estudos Retrospectivos , Fusão Vertebral/economia , Fatores de Tempo , Resultado do TratamentoRESUMO
STUDY DESIGN: Retrospective, observational study. OBJECTIVE: To examine the costs associated with nonoperative management (diagnosis and treatment) of cervical radiculopathy in the year prior to anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA: While the costs of operative treatment have been previously described, less is known about nonoperative management costs of cervical radiculopathy leading up to surgery. METHODS: The Humana claims dataset (2007-2015) was queried to identify adult patients with cervical radiculopathy that underwent ACDF. Outcome endpoint was assessment of cumulative and per-capita costs for nonoperative diagnostic (x-rays, computed tomographic [CT], magnetic resonance imaging [MRI], electromyogram/nerve conduction studies [EMG/NCS]) and treatment modalities (injections, physical therapy [PT], braces, medications, chiropractic services) in the year preceding surgical intervention. RESULTS: Overall 12,514 patients (52% female) with cervical radiculopathy underwent ACDF. Cumulative costs and per-capita costs for nonoperative management, during the year prior to ACDF was $14.3 million and $1143, respectively. All patients underwent at least one diagnostic test (MRI: 86.7%; x-ray: 57.5%; CT: 35.2%) while 73.3% patients received a nonoperative treatment. Diagnostic testing comprised of over 62% of total nonoperative costs ($8.9 million) with MRI constituting the highest total relative spend ($5.3 million; per-capita: $489) followed by CT ($2.6 million; per-capita: $606), x-rays ($0.54 million; per-capita: $76), and EMG/NCS ($0.39 million; per-capita: $467). Conservative treatments comprised of 37.7% of the total nonoperative costs ($5.4 million) with injections costs constituting the highest relative spend ($3.01 million; per-capita: $988) followed by PT ($1.13 million; per-capita: $510) and medications (narcotics: $0.51 million, per-capita $101; gabapentin: $0.21 million, per-capita $93; NSAIDs: 0.107 million, per-capita $47), bracing ($0.25 million; per-capita: $193), and chiropractic services ($0.137 million; per-capita: $193). CONCLUSION: The study quantifies the cumulative and per-capital costs incurred 1-year prior to ACDF in patients with cervical radiculopathy for nonoperative diagnostic and treatment modalities. Approximately two-thirds of the costs associated with cervical radiculopathy are from diagnostic modalities. As institutions begin entering into bundled payments for cervical spine disease, understanding condition specific costs is a critical first step. LEVEL OF EVIDENCE: 3.
Assuntos
Vértebras Cervicais , Custos de Cuidados de Saúde , Formulário de Reclamação de Seguro/economia , Procedimentos Neurocirúrgicos/economia , Radiculopatia/economia , Radiculopatia/terapia , Adulto , Idoso , Vértebras Cervicais/diagnóstico por imagem , Vértebras Cervicais/cirurgia , Estudos de Coortes , Bases de Dados Factuais/economia , Bases de Dados Factuais/tendências , Discotomia/economia , Discotomia/tendências , Feminino , Custos de Cuidados de Saúde/tendências , Humanos , Formulário de Reclamação de Seguro/tendências , Imageamento por Ressonância Magnética/economia , Imageamento por Ressonância Magnética/tendências , Masculino , Manipulação Quiroprática/economia , Manipulação Quiroprática/tendências , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/tendências , Modalidades de Fisioterapia/economia , Modalidades de Fisioterapia/tendências , Radiculopatia/diagnóstico por imagem , Estudos Retrospectivos , Fusão Vertebral/economia , Fusão Vertebral/tendências , Tomografia Computadorizada por Raios X/economia , Tomografia Computadorizada por Raios X/tendências , Resultado do TratamentoRESUMO
STUDY OBJECTIVE: To provide a contemporary medicolegal analysis of claims brought against anesthesia providers in the United States related to neuraxial blocks for surgery and obstetrics. DESIGN: In this retrospective analysis, we analyzed closed claims data from the Controlled Risk Insurance Company (CRICO) Comparative Benchmarking System (CBS) database between 2007 and 2016. SETTING: Closed claims from inpatient and outpatient settings related to neuraxial anesthesia for surgical procedures and obstetrics. PATIENTS: Forty-five claims were identified for analysis. These patients underwent a variety of surgical procedures, included both children and adults, and with ages ranging from 6 to 82. INTERVENTIONS: Patients receiving neuraxial anesthesia (spinals, epidurals) for surgery or obstetrics. MEASUREMENTS: Data collected includes patient demographics, alleged injury type/severity, surgical specialty, likely contributors to the alleged damaging event, and case outcome. Some of the data were drawn directly from coded variables in the CRICO database, and some were gathered from narrative case summaries. MAIN RESULTS: Settlement payments were made in 20% of claims. Reported adverse outcomes ranged from temporary minor to permanent major injuries. Most closed claims were classified as permanent minor injuries. The greatest number of claims involved residual weakness and radiculopathy resulting from epidurals. The largest contributing factor to these injuries was noted to be "Technical Knowledge/Performance" of the anesthesia provider followed by "Missing or Documentation Error." Over half of the claims arose from obstetric patients (31%) and patients undergoing orthopedic surgery (27%). CONCLUSIONS: Patients with pre-existing radiculopathy or comorbidities may warrant more thorough informed consent about the increased risk of injury. Additionally, prompt follow-up, monitoring, and documentation of post-operative symptoms, such as weakness or radiculopathy, are crucial for improving patient safety and satisfaction. More timely communication with the patient and the surgical team regarding residual neurologic symptoms is important for earlier diagnosis of injury.
Assuntos
Anestesia Epidural/efeitos adversos , Anestesia Obstétrica/efeitos adversos , Revisão da Utilização de Seguros/estatística & dados numéricos , Imperícia/estatística & dados numéricos , Complicações Pós-Operatórias/economia , Radiculopatia/economia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Anestesia Epidural/economia , Anestesia Obstétrica/economia , Raquianestesia/efeitos adversos , Raquianestesia/economia , Benchmarking/economia , Benchmarking/legislação & jurisprudência , Benchmarking/estatística & dados numéricos , Criança , Comunicação , Bases de Dados Factuais/estatística & dados numéricos , Feminino , Humanos , Consentimento Livre e Esclarecido/legislação & jurisprudência , Seguro de Responsabilidade Civil/estatística & dados numéricos , Masculino , Imperícia/economia , Imperícia/legislação & jurisprudência , Pessoa de Meia-Idade , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/prevenção & controle , Relações Médico-Paciente , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Gravidez , Radiculopatia/epidemiologia , Radiculopatia/etiologia , Radiculopatia/prevenção & controle , Estudos Retrospectivos , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Estados Unidos/epidemiologia , Adulto JovemRESUMO
STUDY DESIGN: A retrospective study. OBJECTIVE: The aim of this study was to determine hospital costs related to surgery for lumbar radiculopathy and identify determinants of intramural costs based on minimal hospital and claims data. SUMMARY OF BACKGROUND DATA: Costs related to the initial hospitalization of patients undergoing surgery for lumbar radiculopathy make up the major part of direct health care expenditure in this population. Identifying factors influencing intramural costs can be beneficial for health care policy makers, and clinicians working with patients with lumbar radiculopathy. METHODS: The following data were collected from the University Hospital Brussels data warehouse for all patients undergoing surgery for lumbar radiculopathy in 2016 (nâ=â141): age, sex, primary diagnosis, secondary diagnoses, type of surgery, severity of illness (SOI), admission and discharge date, type of hospital admission, and all claims incurred for the particular hospital stay. Descriptive statistics for total hospital costs were performed. Univariate analyses were executed to explore associations between hospital costs and all other variables. Those showing a significant association (Pâ<â0.05) were included in the multivariate general linear model analysis. RESULTS: Mean total hospital costs were &OV0556; 5016â±â188 per patient. Costs related to the actual residence (i.e., "hotel costs") comprised 53% of the total hospital costs, whereas 18% of the costs were claimed for the surgical procedure. Patients with moderate/major SOI had 44% higher hospital costs than minor SOI (Pâ=â0.01). Presence of preadmission comorbidities incurred 46% higher costs (Pâ=â0.03). Emergency procedures led to 72% higher costs than elective surgery (Pâ<â0.001). Patients receiving spinal fusion had 211% higher hospital costs than patients not receiving this intervention (Pâ<â0.001). CONCLUSION: Hospital costs in patients receiving surgery for lumbar radiculopathy are influenced by SOI, the presence of preadmission comorbidities, type of hospital admission (emergency vs. elective), and type of surgical procedure. LEVEL OF EVIDENCE: 3.
Assuntos
Custos Hospitalares , Hospitalização/economia , Tempo de Internação/economia , Radiculopatia/cirurgia , Fusão Vertebral/economia , Idoso , Procedimentos Cirúrgicos Eletivos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Radiculopatia/economia , Estudos RetrospectivosRESUMO
INTRODUCTION: This study directly compares the economical and clinical effectiveness of the use of cervical epidural injections and continued physical therapy versus surgical management in cases of cervical radiculopathy that have failed 6 weeks of conservative management. METHODS: A theoretical cohort of patients with cervical radiculopathy resistant to 6 weeks of noninvasive conservative management were simulated to treatment with either anterior cervical diskectomy and fusion (ACDF) or cervical epidural injections and continued physical therapy and analyzed with Markov chain decision tree Monte Carlo simulation. RESULTS: The average incremental cost-effectiveness ratio associated with ACDF was $6,768 per quality-adjusted life year over the lifetime of the patient, whereas the incremental cost-effectiveness ratio associated with cervical injections ranged from $9,033 to $4,044 per quality-adjusted life year based on the success rate. DISCUSSION: Our study suggests that for the management of recalcitrant cervical radiculopathy, ACDF remains the dominant strategy compared with cervical epidural injections if the surgical avoidance rate of such injections is less than 50%. If there is a greater than 50% surgery avoidance rate with injections, then cervical epidural injections would be considered a cost-effective strategy with a role in the management of cervical radiculopathy before surgery.
Assuntos
Tratamento Conservador/economia , Análise Custo-Benefício , Discotomia/economia , Radiculopatia/economia , Radiculopatia/terapia , Fusão Vertebral/economia , Estudos de Coortes , Feminino , Humanos , Injeções Epidurais/economia , Masculino , Pessoa de Meia-Idade , Método de Monte Carlo , Modalidades de Fisioterapia/economia , Resultado do TratamentoRESUMO
INTRODUCTION: Cervical radiculopathy due to discogenic or spondylotic stenosis of the neuroforamen can be surgically treated by an anterior discectomy with fusion (ACDF) or a posterior foraminotomy (FOR). Most surgeons prefer ACDF, although there are indications that FOR is as effective as ACDF, has a lower complication rate and is less expensive. A head-to-head comparison of the 2 surgical techniques in a randomised controlled trial has not yet been performed. The study objectives of the Foraminotomy ACDF Cost-Effectiveness Trial (FACET) study are to compare clinical outcomes, complication rates and cost-effectiveness of FOR to ACDF. METHODS AND ANALYSIS: The FACET study is a prospective randomised controlled trial conducted in 7 medical centres in the Netherlands. The follow-up period is 2â years. The main inclusion criterion is a radiculopathy of the C4, C5, C6 or C7 nerve root, due to a single-level isolated cervical foraminal stenosis caused by a soft disc and/or osteophytic component, requiring operative decompression. A sample size of 308 patients is required to test the hypothesis of clinical non-inferiority of FOR versus ACDF. Primary outcomes are: 'operative success', the measured decrease in radiculopathy assessed by the visual analogue scale and 'patient success', assessed by the modified Odom's criteria. Secondary outcomes are: Work Ability Index (single-item WAI), quality of life (EuroQol 5 Dimensions 5 level Survey, EQ-5D-5L), Neck Disability Index (NDI) and complications. An economic evaluation will assess cost-effectiveness. In addition, a budget impact analysis will be performed. ETHICS AND DISSEMINATION: Ethical approval was obtained from the Institutional Ethics Committee of the University Medical Center Groningen. Results of this study will be disseminated through national and international papers. The participants and relevant patient support groups will be informed about the results of the study. TRIAL REGISTRATION NUMBER: NTR5536, pre-results.
Assuntos
Discotomia , Foraminotomia , Radiculopatia/economia , Radiculopatia/cirurgia , Fusão Vertebral , Vértebras Cervicais , Análise Custo-Benefício , Avaliação da Deficiência , Discotomia/efeitos adversos , Discotomia/economia , Discotomia/métodos , Seguimentos , Foraminotomia/efeitos adversos , Foraminotomia/economia , Humanos , Qualidade de Vida , Projetos de Pesquisa , Método Simples-Cego , Fusão Vertebral/efeitos adversos , Fusão Vertebral/economia , Resultado do TratamentoRESUMO
BACKGROUND: The cost of low back pain was the subject of few studies in black Africa. AIM: To assess the cost of common low back pain and lumbar radiculopathy in Lomé. METHODS: A six months study was realised in the rheumatologic department of CHU Sylvanus Olympio. 103 consecutive patients suffering from a common low back pain or lumbar radiculopathy were included. To assess direct, indirect and non-financial costs they were questioned about their expense during the year. RESULTS: Financial cost of common low back pain and lumbar radiculopathy amounted to 107.2 $ US (extremes: 5.8 and 726.1 $ US). This amount, quadruple of guaranteed minimum wage, felled under two headings: direct cost (56.3 $ US; 53% of total sum), indirect cost (50.3 $ US; 47% of total sum). Non-financial cost were: disruption in daily activities (94%), impact in emotional and sexual life (59%), impact on the family's budget (69%), abandon of family's projects (58%) or of leisure (42%). CONCLUSION: In black Africa top priority is given to the fight against infectious diseases those cause an important mortality. But common low back pain and lumbar radiculopathy, those have social and economic impact, should be given more attention.
Assuntos
Dor Lombar/economia , Dor Lombar/epidemiologia , Radiculopatia/economia , Radiculopatia/epidemiologia , Encaminhamento e Consulta , Adolescente , Adulto , Idoso , Artrite Reumatoide/complicações , Artrite Reumatoide/economia , Artrite Reumatoide/epidemiologia , Artrite Reumatoide/terapia , Análise Custo-Benefício , Feminino , Custos de Cuidados de Saúde , Humanos , Dor Lombar/terapia , Masculino , Pessoa de Meia-Idade , Radiculopatia/terapia , Encaminhamento e Consulta/economia , Encaminhamento e Consulta/estatística & dados numéricos , Reumatologia/estatística & dados numéricos , Togo/epidemiologia , Adulto JovemRESUMO
AIMS OF THE STUDY: To assess the cost-effectiveness of primarily surgical treatment (PST) versus primarily conservative treatment (PCT) in adults with intermediate severity, acute or subacute, lumbar radicular syndrome due to intervertebral disc herniation. METHODS: A decision analytic model from healthcare system and societal perspectives was used to compare outcomes and costs of PST with those of PCT (physiotherapy, epidural injection and medication). Treatment pathways and quality of life were obtained from published clinical trials. Costs were derived from Swiss health insurance claims data. Swiss clinical experts provided information on use of medication and physiotherapy. The main outcome of interest was incremental cost per quality-adjusted-life-year (QALY) gained over a period of 2 years. Costs and QALYs gained were discounted from the second year, at a rate of 2% per year. RESULTS: In the base-case analysis from a healthcare system perspective, over 2 years, PST compared with PCT led to 0.0634 additional QALYs per person, at an additional net cost of CHF 7198 per person. The corresponding incremental cost effectiveness ratio (ICER) amounted to CHF 113 396 per QALY gained. From a societal perspective the ICER was CHF 70 711 per QALY gained. ICERs were subject to substantial uncertainty because of limitations in available data. CONCLUSION: A PST approach, when compared with PCT, may be cost effective from a societal perspective based on a willingness-to-pay threshold of CHF 100 000 per QALY gained. However, it is less likely to be cost effective from the perspective of the Swiss healthcare system. More research is needed to understand the long-term economic implications among this patient group.
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Tratamento Conservador/economia , Deslocamento do Disco Intervertebral/complicações , Radiculopatia/economia , Radiculopatia/etiologia , Radiculopatia/terapia , Efeitos Psicossociais da Doença , Análise Custo-Benefício , Técnicas de Apoio para a Decisão , Feminino , Humanos , Revisão da Utilização de Seguros , Vértebras Lombares , Masculino , Modelos Econômicos , Método de Monte Carlo , Procedimentos Neurocirúrgicos/economia , Modalidades de Fisioterapia/economia , Medicamentos sob Prescrição/economia , Medicamentos sob Prescrição/uso terapêutico , Qualidade de Vida , Anos de Vida Ajustados por Qualidade de Vida , Radiculopatia/cirurgia , Índice de Gravidade de Doença , SuíçaRESUMO
STUDY DESIGN: A retrospective 1-year cost-utility analysis. OBJECTIVE: To determine the cost-effectiveness of anterior cervical discectomy and fusion with plating (ACDFP) in comparison with posterior cervical foraminotomy (PCF) for patients with single-level cervical radiculopathy. SUMMARY OF BACKGROUND DATA: Cervical radiculopathy due to cervical spondylosis is commonly treated by either PCF or ACDFP for patients who are refractory to nonsurgical treatment. Although some have suggested superior outcomes with ACDFP as compared with PCF, the former is also associated with greater costs. The present study analyzes the cost-effectiveness of ACDFP versus PCF for patients with single-level cervical radiculopathy. METHODS: Forty-five patients who underwent ACDFP and 25 patients who underwent PCF for single-level cervical radiculopathy were analyzed. One-year postoperative health outcomes were assessed based on Visual Analogue Scale, Pain Disability Questionnaire, Patient Health Questionnaire, and EuroQOL-5 Dimensions questionnaires to analyze the comparative effectiveness of each procedure. Direct medical costs were estimated using Medicare national payment amounts and indirect costs were based on patient missed work days and patient income. Postoperative 1-year cost/utility ratios and the incremental cost-effectiveness ratio (ICER) were calculated to assess for cost-effectiveness using a threshold of $100,000/QALY gained. RESULTS: The 1-year cost-utility ratio for the PCF cohort was significantly lower ($79,856/QALY gained) than that for the ACDFP cohort ($131,951/QALY gained) (P<0.01). In calculating the 1-year ICER, as the ACDFP cohort showed lower QALY gained than the PCF cohort, the ICER was negative and is not reported, meaning that ACDFP was dominated by PCF. CONCLUSIONS: Statistically significant and clinically relevant improvements (through minimum clinically important differences) were seen in both cohorts. Although both cohorts showed improved health outcomes, ACDFP was not cost-effective relative to the threshold of $100,000/QALY gained at 1-year postoperatively, whereas PCF was. The durability of these results must be analyzed with long-term cost-utility analysis studies.
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Vértebras Cervicais/cirurgia , Análise Custo-Benefício , Discotomia/economia , Foraminotomia/economia , Radiculopatia/economia , Radiculopatia/cirurgia , Fusão Vertebral/economia , Demografia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do TratamentoRESUMO
OBJECTIVE: To compare the clinical efficacy on cervical spondylotic radiculopathy between the combined therapy of massage and magnetic-sticking at the auricular points and the simple massage therapy, and conduct the health economics evaluation. METHODS: Seventy-two patients of cervical spondylotic radiculopathy were randomized into a combined therapy group, and a simple massage group, 36 cases in each one. Finally, 35 cases and 34 cases were met the inclusive criteria in the corresponding groups separately. In the combined therapy group, the massage therapy and the magnetic sticking therapy at auricular points were combined in the treatment. Massage therapy was mainly applied to Fengchi (GB 20), Jianjing (GB 21), Jianwaishu (SI 14), Jianyu (LI 15) and Quchi (LI 11). The main auricular points for magnetic sticking pressure were Jingzhui (AH13), Gan (On12) Shen (CO10), Shenmen (TF4), Pizhixia (AT4). In the simple massage group, the simple massage therapy was given, the massage parts and methods were the same as those in the combined therapy group. The treatment was given once every two days, three times a week, for 4 weeks totally. The cervical spondylosis effect scale and the simplified McGill pain questionnaire were adopted to observe the improvements in the clinical symptoms, clinical examination, daily life movement, superficial muscular pain in the neck and the health economics cost in the patients of the two groups. The effect was evaluated in the two groups. RESULTS: The effective rate and the clinical curative rate in the combined therapy group were better than those in the control group [100. 0% (35/35) vs 85. 3% (29/34), 42. 9% (15/35) vs 17. 6% (6/34), both P<0. 05]. The scores of the spontaneous symptoms, clinical examnation, daily life movement and superficialmuscular pain in the neck were improved apparently after treatment as compared with those before treatment in the patients of the two groups (all P<0. 001). In terms of the improvements in the spontaneous symptoms, clinical examination total scores and superficial muscular pain in the' neck were more significant in the combined therapy group as compared with those in the simple massage group (P<0. 05, P<0. 01, P<0. 001). The cost at the unit effect in the combined therapy group was lower than that in the simple massage group (P<0. 05). CONCLUSION: Compared with the simple massage therapy, the massage therapy combined with magnetic sticking therapy at auricular points achieves the better effect and lower cost in health economics.
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Acupuntura Auricular , Magnetoterapia , Massagem , Radiculopatia/terapia , Espondilose/terapia , Pontos de Acupuntura , Acupuntura Auricular/economia , Adulto , Idoso , Terapia Combinada/economia , Feminino , Humanos , Magnetoterapia/economia , Masculino , Massagem/economia , Pessoa de Meia-Idade , Radiculopatia/economia , Espondilose/economia , Resultado do TratamentoRESUMO
BACKGROUND: Few studies have examined the general correlation between socioeconomic status and imaging. This study is the first to analyze this relationship in the spine patient population. OBJECTIVE: To assess the effect of socioeconomic status on the frequency with which imaging studies of the lumbar spine are ordered and completed. METHODS: Patients that were diagnosed with lumbar radiculopathy and/or myelopathy and had at least 1 subsequent lumbar magnetic resonance imaging (MRI), computed tomography (CT), or X-ray ordered were retrospectively identified. Demographic information and the number of ordered and completed imaging studies were among the data collected. Patient insurance status and income level (estimated based on zip code) served as representations of socioeconomic status. RESULTS: A total of 24,105 patients met the inclusion criteria for this study. Regression analyses demonstrated that uninsured patients were significantly less likely to have an MRI, CT, or X-ray study ordered (P < .001 for all modalities) and completed (P < .001 for MRI and X-ray, P = .03 for CT). Patients with lower income had higher rates of MRI, CT, and X-ray (P < .001 for all) imaging ordered but were less likely to have an ordered X-ray be completed (P = .009). There was no significant difference in the completion rate of ordered MRIs or CTs. CONCLUSION: Disparities in image utilization based on socioeconomic characteristics such as insurance status and income level highlight a critical gap in access to health care. Physicians should work to mitigate the influence of such factors when deciding whether to order imaging studies, especially in light of the ongoing shift in health policy in the United States.
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Disparidades em Assistência à Saúde/economia , Vértebras Lombares/diagnóstico por imagem , Imageamento por Ressonância Magnética/economia , Classe Social , Tomografia Computadorizada por Raios X/economia , Feminino , Humanos , Cobertura do Seguro/economia , Vértebras Lombares/patologia , Imageamento por Ressonância Magnética/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Radiculopatia/diagnóstico , Radiculopatia/diagnóstico por imagem , Radiculopatia/economia , Análise de Regressão , Estudos Retrospectivos , Doenças da Medula Espinal/diagnóstico , Doenças da Medula Espinal/diagnóstico por imagem , Doenças da Medula Espinal/economia , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Estados UnidosRESUMO
OBJECT: Delayed cervical palsy (DCP) is a known complication following cervical spine surgery. While most DCPs eventually improve, they can result in significant temporary disability. Postoperative complications affect hospital length of stay (LOS) as well as overall hospital cost. The authors sought to determine the hospital cost of DCP after cervical spine fusion operations. METHODS: A retrospective review of patients undergoing cervical fusion for degenerative disease at the Mayo Clinic from 2008 to 2012 was performed. Patients who developed DCPs not attributable to intraoperative trauma were included. All nonoperative-related costs were compared with similar costs in a control group matched according to age, sex, and surgical approach. All costs and services were reflective of the standard costs for the current year. Raw cost data were presented using ratios due to institutional policy against publishing cost data. RESULTS: There were 27 patients (18 men, 9 women) who underwent fusion and developed a DCP over the study period. These patients were compared with 24 controls (15 men, 9 women) undergoing fusion in the same time period. There was no difference between patients and controls in mean age (62.4 ± 3.1 years vs. 63.8 ± 2.5 years, respectively; p = 0.74), LOS (4.2 ± 3.3 days vs 3.8 ± 4.5 days, respectively; p = 0.43), or operating room-related costs (1.08 ± 0.09 vs. 1.0 ± 0.07, respectively; p = 0.58). There was a significant difference in nonoperative hospital-related costs between patients and controls (1.67 ± 0.15 vs 1.0 ± 0.09, respectively; p = 0.04). There was a significantly higher utilization of postoperative imaging (CT or MRI) in the DCP group (14/27, 52%) when compared with the matched cohort (4/24, 17%; p = 0.018), and a significantly higher utilization of physiatry services (24/27 [89%] vs 15/24 [63%], respectively; p = 0.046). CONCLUSIONS: While DCPs did not significantly prolong the length of hospitalization, they did increase hospital-related costs. This method could be further extrapolated to model costs of other complications as well.
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Vértebras Cervicais/cirurgia , Descompressão Cirúrgica/efeitos adversos , Paralisia/etiologia , Radiculopatia/etiologia , Fusão Vertebral/efeitos adversos , Raízes Nervosas Espinhais/lesões , Idoso , Descompressão Cirúrgica/economia , Feminino , Custos Hospitalares , Humanos , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Paralisia/economia , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/etiologia , Radiculopatia/economia , Estudos Retrospectivos , Fusão Vertebral/economia , Raízes Nervosas Espinhais/cirurgiaRESUMO
OBJECTIVE: To investigate the effect of adding segmental epidural steroid injections (SESIs) to usual care compared with usual care alone on quality of life and cost utility in lumbosacral radicular syndrome (LRS) in general practice. DESIGN: A pragmatic randomized controlled trial. Results were analyzed using mixed models. SETTING: Primary care. PARTICIPANTS: Patients (N=50) in the acute phase of LRS. INTERVENTIONS: One epidural injection containing 80mg of triamcinolone in normal saline. MAIN OUTCOME MEASURE: Back pain at 4 weeks after the start of the treatment. RESULTS: Both groups experienced a significant increase in quality of life in (especially) the physical domains of the Medical Outcomes Study 36-Item Short-Form Health Survey. The intervention group scored significantly better than the control group at certain time points in the physical domain. The differences were small. The cost-utility analysis showed that with a negligible loss of utility (3d in perfect health), societal costs (193,354 euros per quality-adjusted life year lost) would be saved because of more productivity in the intervention group. CONCLUSIONS: Although the beneficial effects of SESIs are small and the natural course of LRS is predominantly favorable, we think decision makers can consider implementing SESIs in daily practice with the purpose of saving resources. Caution must be taken, and further research should be directed at identifying patient subgroups who might benefit from SESIs, with additional focus on (costs of) complications and adverse effects.
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Medicina de Família e Comunidade , Glucocorticoides/administração & dosagem , Glucocorticoides/economia , Região Lombossacral , Qualidade de Vida , Radiculopatia/tratamento farmacológico , Radiculopatia/economia , Triancinolona/administração & dosagem , Triancinolona/economia , Adolescente , Adulto , Idoso , Análise Custo-Benefício , Feminino , Humanos , Injeções Epidurais , Masculino , Pessoa de Meia-Idade , Anos de Vida Ajustados por Qualidade de Vida , Síndrome , Resultado do TratamentoRESUMO
OBJECT: Patients suffering from cervical radiculopathy in whom a course of nonoperative treatment has failed are often candidates for a single-level anterior cervical discectomy and fusion (ACDF) or posterior cervical foraminotomy (PCF). The objective of this analysis was to identify any significant cost differences between these surgical methods by comparing direct costs to the hospital. Furthermore, patient-specific characteristics were also considered for their effect on component costs. METHODS: After obtaining approval from the medical center institutional review board, the authors conducted a retrospective cross-sectional comparative cohort study, with a sample of 101 patients diagnosed with cervical radiculopathy and who underwent an initial single-level ACDF or minimally invasive PCF during a 3-year period. Using these data, bivariate analyses were conducted to determine significant differences in direct total procedure and component costs between surgical techniques. Factorial ANOVAs were also conducted to determine any relationship between patient sex and smoking status to the component costs per surgery. RESULTS: The mean total direct cost for an ACDF was $8192, and the mean total direct cost for a PCF was $4320. There were significant differences in the cost components for direct costs and operating room supply costs. It was found that there was no statistically significant difference in component costs with regard to patient sex or smoking status. CONCLUSIONS: In the management of single-level cervical radiculopathy, the present analysis has revealed that the average cost of an ACDF is 89% more than a PCF. This increased cost is largely due to the cost of surgical implants. These results do not appear to be dependent on patient sex or smoking status. When combined with results from previous studies highlighting the comparable patient outcomes for either procedure, the authors' findings suggest that from a health care economics standpoint, physicians should consider a minimally invasive PCF in the treatment of cervical radiculopathy.